San Joaquin Valley Air Pollution Control District

Supplemental Application Form

Wastewater Treatment Operations

This form must be accompanied by a completed Authority to Construct/Permit to Operate Application form

PERMIT TO BE ISSUED TO:
LOCATION WHERE THE EQUIPMENT WILL BE OPERATED:

Facility Description

/ Does this facility receive offsite wastes? [ ] Yes [ ] No / Is this facility publicly owned? [ ] Yes [ ] No
Process Flow Rate (design capacity): ______gal/day______gal/week______gal/year
Description of Wastes Treated:

Process Description

/ Please list the process units in order. Please attach a process flow diagram. Attach additional pages, if needed. Examples of individual units are: DAF/grit separator, aeration channel, equalization tank, trickling filter, pond, etc.
1. / 8.
2. / 9.
3. / 10.
4. / 11.
5. / 12.
6. / 13.
7. / 14.
Total Electric Horsepower Rating of all Equipment:

Currently Permitted Units

/ Please use SJVAPCD Permit to Operate №
1. / 3.
2. / 4.

Analytical Data

Inlet Concentrations

/ Total Organics / ______g/L
Benzene / ______g/L / Tetrachloroethylene / ______g/L
Chloroform / ______g/L / Toluene / ______g/L
1,4-Dichlorobenzene / ______g/L / 1,1,1-Trichloroethane / ______g/L
Methylene Chloride / ______g/L / Trichloroethene / ______g/L
Methyl t-Butyl Ether / ______g/L / Xylenes (total) / ______g/L

Analytical Data

/ Attach recent influent and effluent analytical data including priority pollutants, BOD, T.S.S. (organic), pH.

Please see other side for additional information required.

HEALTH RISK ASSESSMENT DATA

Operating Hours
/ Maximum Operating Schedule: ______hours per day, and ______hours per year
Receptor Data / Distance to nearest Residence / ______feet / Distance is measured from the emissions unit to the nearest boundary of the nearest apartment, house, dormitory, etc.
Direction to nearest Residence / Direction from the emissions unit to the receptor, e.g. N, NE, E, SE, S, SW, W, NW.
Distance to nearest Business / ______feet / Distance is measured from the emissions unit to the nearest boundary of the nearest office building, factory, store, etc.
Direction to nearest Business / Direction from the emissions unit to the receptor, e.g. see above.
Evaporation Emission Parameters
/ Release Height / ______feet / Release height measured from the ground to the top of the source. For example, if a pond has a three foot berm surrounding it. The physical height of the pond is three feet.
Release Area / Provide the surface area dimensions of the emissions unit, e.g. 12 feet x 12 feet, 10 feet diameter, etc.
Exhaust Stack Parameters
/ Release Height / ______feet above grade
Stack Diameter / ______inches at point of release
Rain Cap / [ ] Flapper-type [ ] Fixed-type [ ] None [ ] Other: ______
Flowrate / ______acfm / Temperature / ______F
Direction of Flow / [ ] Vertically Upward [ ] Horizontal [ ] Other: ___ from vert. or ___ from horiz.
Facility Location / [ ] Urban (area of dense population) [ ] Rural (area of sparse population)

FOR DISTRICT USE ONLY

Date: / FID: / Project: / Public Notice: [ ] Yes [ ] No
Comments: